Premarital sex and condom use among trainee healthcare workers: an exploratory study of selected healthcare training institutions in Enugu State, Nigeria

Introduction To assess the prevalence and causes of premarital sex and condom use among trainee healthcare workers in selected healthcare institutions in Enugu State, Nigeria; and to proffer solution to challenges identified. Methods We used a mixed study approach with qualitative and quantitative components. Informed consent was obtained from participants and data collected using self-administered structured questionnaires. Epi info® was used for data analysis. Results A total of 362 respondents (309 unmarried) from four healthcare training institutions participated in the study. Among unmarried respondents, 141 (45.8%) were sexually active. Premarital sex was more common among Pentecostals and sexual activity increased with age (r=0.78; p <0.05). Premarital sexual activity was more common among males and trainee nurses (p <0.005). Although knowledge of condom use was high, actual use was poor (20.1%), with lowest rates among females, Catholics and age-group 30-35 years. Breakages, high failure rates and reduced sexual satisfaction were cited as major factors responsible for poor use. Use of non-specific terms such as "casual sex" and "casual or regular sex partners" hindered consistent, correct condom use. Conclusion There is a significant gap between knowledge of and actual use of condoms, despite high premarital sexual activity amongst healthcare workers. Furthermore, non-specific terminologies hinders appropriate condom usage. We propose the term: Committed Spousal Partner (CSP) defined as "a sexual partner who commits to fidelity (one sexual partner per time) and whose current HIV status is known through medical testing and is properly documented" in place of all non-specific terminology.


Introduction
Human immune deficiency virus (HIV) infection with resultant acquired immune deficiency syndrome (AIDS) is one of the few diseases almost entirely preventable through simple measures.
Despite this, close to 40 years after the discovery of HIV in the 1980s, the disease is still spreading. Sexual intercourse (including men having sex with men) has remained a major source of transmission of HIV across the world [1], as has unprotected premarital sex and sex with sex workers. Peer pressure and the broadcast media also contribute, instigating adolescents into risky behavior and illicit substance use, while facilitating the spread of disease [2]. Premarital sex among students is a common phenomenon [3][4][5][6] and is of particular importance because adolescent and young adults between 15-24 years of age account for a vast proportion of newly acquired sexually transmitted diseases [7]. Another facilitator of the spread of sexually transmitted diseases is the improper, sporadic, or lack of use of condoms, which may be due to a number of factors, including: pressure from male partners not to use protection, alcohol consumption prior to sexual intercourse increasing risk-taking behaviour, need for money forcing women into becoming sex workers and rape [8]. In a study of sexually active locals from Java, Indonesia, 60% did not take any action to prevent sexuallytransmitted diseases (STD) or pregnancy during their last sexual encounter [9]. Other studies have shown that condom use varies with geographical location [10] and is low with regular partners, even amongst high-risk populations like injecting drug users [9].
Healthcare workers should be knowledgeable of HIV and have a favorable attitude towards its prevention [11]. Although there have been studies on premarital sex and condom usage among students [3][4][5][6], none has specifically focused on students in medical and allied healthcare professions. The objective of this study was to assess the prevalence of premarital sex and the use of condoms among trainee healthcare workers in selected healthcare institutions in Enugu State, southeastern Nigeria. It was also designed to document their level(s) and appropriateness of condom use. To achieve these objectives, three research questions were used: (1) What is the prevalence of premarital sex among students in selected institutions of higher learning?; (2)  Research permission was obtained from the University of Benin. We also received consent from the participating institutions and participants before their inclusion in the survey. A pre-tested Self-Administered Questionnaire (SAQ) was used for data collection. Epi info® (https://www.cdc.gov/epiinfo) and MS Excel were used for data analysis.
Ethical approval: This article is a cross sectional study and does not contain any studies with human participants or animals performed by any of the authors.

Results
A total of 362 respondents from the four healthcare training institutions were enlisted in the study. Of these 362, 361 respondents returned their self-administered questionnaires, giving a response rate of 99.7%. However, some questionnaires were not completed fully ( Table 1). The majority of participants were drawn from the School of Nursing (Figure 1). Of the 361 participants, 308 (85.1%) were unmarried. Close to 80% of all participants were females (247, 79.9%). The mean age of participants was 24.41 ± 5.6 years, and the majority identified as Catholic (173, 58.6%).
Radio was the main source of reproductive and sexual health information.
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Knowledge of HIV/AIDS and condoms:
A total of 298 participants (96.4%) knew that AIDS is an infection, while 277 (89.6%) knew that HIV is a virus. The highest level of knowledge was found among postgraduate nurses and midwives (100%), while levels of knowledge were lower among students of the Institute of Medical Laboratory Science (94.6%) and first year basic nursing students (94.6%). Wrong responses given included: "AIDS is a curse", "HIV is an infection" and "HIV means Higher Immune Vaccine". The level of knowledge between the different participating schools were not significantly different at 95% CI (X 2 = 0.52; p>0.05) All participants had heard of condoms, but only 290 (93.8%) had previously seen one. While all midwifes and postgraduate nursing students had previously seen condoms, rates of 80.3% were reported in first year nursing students. Generally, more of the sexually active participants had seen a condom before, but this difference was not statistically significant (p>0.05).

Attitude to HIV/AIDS and condoms:
One hundred and ten (35.6%) respondents believed that they were at risk of HIV. More of the sexually active participants accepted they were at risk of HIV infection than the non-sexually active (36.6% vs. 23.4%, respectively) (X = 7.44, P<0.01). Fifty-eight (18.8%) respondents reported that they would have sex (with or without condoms) if they were HIV positive. This was reported as being in order to satisfy their sexual needs, as sex was seen as a basic human right that needed to be satisfied by 22 (57.9%) of respondents. Thirty-three (56.9%) respondents reported that they would have sex if HIV was status positive, either to satisfy their desires or that of their partner(s) or spouse. Other reasons are listed in Table 2.
To support her desire to have sex with or without a condom, one

Discussion
There was a significant difference between levels of premarital sexual activity of trainee nurses, when compared with medical laboratory trainees. Male trainees were more sexually active than females. Despite high premarital sexual activity amongst surveyed healthcare workers, condom use was poor. Although knowledge of condom use was high, actual and consistent use was poor, resulting in a gap between knowledge of condom usage and actual practice.
This finding is similar to studies from across the world. For instance, in an Indian study, nearly half of respondents (48.4%) used condoms inconsistently even amongst female sex workers and those engaging in anal sex with other men [12]. A study in Singapore reported consistent condom use with paid or casual partners of 39.6% and 36.2% for vaginal and oral sex, respectively [13].
Another study designed to examine prevalence and determinants of condom use among female undergraduates at 16 university campuses in China revealed 18.1% having sexual intercourse, with 19.8% having used a condom in their first sexual encounter [5]. In that study, 30% of those having intercourse reported never, seldom or sometimes using condoms in the past 12 months [5]. A Canadian study using a national sample of 653 Canadian university students reported higher condom usage amongst men than women (55.4% and 42.3%, respectively) [14], similar to the findings of this study.
Being over 25 years of age, not a manual laborer and the perception that the respondent might be at risk of HIV, were factors that positively affected condom usage [12,13]. Also in the Canadian study, female students who had sex with a more committed partner had slightly lower odds of reporting condom use at last penile vaginal intercourse [14]. A Philippine study revealed that 42% of the study population did not always use condoms [15], assertions echoed in other studies [16]. These findings, similar to the findings of this study, show that although premarital sex rates are high, condom use is poor, even among healthcare students. Poor condom use is worsened by the use of non-specific terms like "casual sex" and "casual or regular-sex partners". As these words are poorly defined, there is a need for a more specific terminology that explicitly specifies what is needed for safer sex among unmarried sexually active people.

Conclusion
We found substantial gaps between knowledge, attitude and  "Casual sex partner" is an ill-defined term. We propose the use of Committed Spousal Partner (CSP) in place of all non-specific and poorly defined terms. We define a CSP as: "a sexual partner who commits to fidelity (one sexual partner per time) and whose current HIV status is known through medical testing and is properly documented." A committed spousal partner's status can change to noncommitted spousal partner when any of these conditions are violated.

Competing interests
The authors declare no competing interests.